ATI:
RN
Adult
Medical
Surgical
Kidney
Disease
Using
the
SBAR
format,
identify
the
info.
Nurse
Allyson
received
from
report
that
will
enable
her
to
provide
safe
care
to
Mr.
Jones.
-
ANS
S-
Situation
The
ED
admitted
Mr.
Jones
at
4:30
AM
for
SOB
and
weakness.
After
treatment,
he
is
transferring
to
the
telemetry
unit.
B
-
Background
60
year
old
African-American
male
with
a
history
of
peripheral
vascular
disease,
type
2
diabetes,
chronic
kidney
disease,
coronary
artery
disease,
and
atrial
fibrillation.
A
provider
recently
discharged
him
from
the
facility
after
he
treated
Mr.
Jones
for
atrial
fibrillation
and
a
type
2
diabetic
ulcer
of
the
right
foot.
Mr.
Jones
did
not
complete
prescribed
antibiotics
after
his
discharge.
He
is
non
compliant
in
managing
his
diabetes.
He
smokes
one
pack
of
cigarettes
a
day
and
uses
alcohol
3
to
5
times
a
week.
A
-
Assessment
Mr.
Jones
is
awake,
alert,
and
orientated
x3.
Current
vitals
are:
BP
112/70,
P:
158,
R:
34,
T:
99.1,
and
O2
sat
91%
on
2
L
via
nasal
cannula.
ECG
indicates
atrial
fibrillation;
placed
on
telemetry.
Chest
x-ray:
opacities
greater
in
the
right
lung
than
left
lung.
Altered
lab
values
include:
sodium
128,
potassium
5.1,
BU
Nurse
Allyson
is
preparing
to
perform
a
sterile
dressing
change
to
Mr.
Jones's
foot.
After
removing
the
exam
gloves,
performing
hand
hygiene,
and
gathering
the
needed
supplies,
what
are
the
next
steps
Nurse
Allyson
should
take
for
the
dressing
change?
-
ANS
1.
Apply
clean
gloves.
2.
Remove
dressing
and
place
in
moisture-proof
bag.
3.
Remove
clean
gloves.
4.
Wash
hands.
5.
Apply
sterile
gloves.
6.
Cover
with
sterile
gauze.
7.
Secure
dressing.
Nurse
Allyson
is
preparing
to
call
the
provider
about
Mr.
Jones's
difficulty
breathing.
Which
of
the
following
orders
should
she
recommend
to
the
provider?
-
ANS
Furosemide
(Lasix)
20
mg
IV
Mr.
Jones's
total
urinary
output
is
50
mL.
His
total
IV
fluid
intake
since
admission
is
1550
mL.
Which
of
the
following
is
an
appropriate
nursing
intervention
at
this
time?
-
ANS
Obtain
a
bladder
scan.
Nurse
Allyson
is
going
to
perform
a
bladder
scan
on
Mr.
Jones.
Where
should
the
transducer
be
placed
on
his
abdomen?
-
ANS
Central
abdomen,
below
the
umbilicus.
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